Lip Piercing

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Clinicalp r a c t i c E

ContactAuthor

Body piercing is a cultural practice ortradition in various civilizations dating

back to antiquity. In recent years, body

piercing has become increasingly ashionable

or purely esthetic reasons, and the practice

cuts across all sectors o society. Te emer-gence o oral piercing, especial ly among young

adults, is o concern to dental and medical

proessionals because o the risks and com-

plications or oral, dental and general health.

Intraoral piercings involve the tongue, whileperioral piercings involve the lips, the cheeks

and, to a lesser extent, the uvula and therenum. Among those with non-traditional

body piercings, the tongue is the most preva-

lent site ollowed by the lips.1 Since the rst

warnings by Chen and Scully in 19922 o therisks and complications associated with oral

piercings, an increasing number o studies on

this issue have been published. Risks and com-

plications (Box 1) are diverse and range rom

temporary inconveniences related to the pres-ence o the jewellery in the mouth, to gingival

recession and severe systemic inections.

In this article, we present a brie reviewo the current literature on potential compli-cations and adverse consequences o tongueand lip piercings. Our objective is to provide

a general overview o possible problems thatmay be encountered by dentists. In addition,we highlight the urgent need or dentists and

doctors to inorm target patients o the risksassociated with oral piercings.

OralPiercingProcedures

Te tongue is usually pierced at the mid-

line, typically in the median lingual sulcus,although piercings may also be perormed onthe dorsolateral lingual surace anterior to the

lingual renum. Te principal type o jewelleryused in tongue piercings is barbells, whichconsist o a bar with a ball screwed onto each

end. Lip piercings are mainly perormed onthe middle portion o the lower lip, but mayalso be near the commissura and on the lower

lip near the canines. Labrets, with the fatend on the mucosal side o the lip, as well asrings and barbells, are commonly used or lip

Dr. Grenier

Email:[email protected]

Overview of Complications Secondaryto Tongue and Lip Piercings

Lo-Franois Maheu-Robert, DMD; Elisoa Andrian, PhD; Daniel Grenier, PhD

ABSTRACT

In recent years, intraoral and perioral piercings have grown in popularity among teen-

agers and young adults. This is of concern to dental and medical professionals because

of the risks and complications for oral, dental and general health. The risks and compli-

cations associated with tongue and lip piercings range from abnormal tooth wear and

cracked tooth syndrome to gingival recession and systemic infections. In this report, we

provide an overview of possible problems associated with oral piercings that may beencountered by dentists.

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-73/issue-4/327.html
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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piercings. Aer the piercing procedure, regular rinsing

with warm salt water or antiseptic mouthwash is sug-

gested, and smoking and alcoholic beverages should be

avoided. It is generally recommended that the jewellery

not be removed or a long period to prevent the piercing

site rom closing spontaneously. However, once healing

is complete, the jewellery should be removed daily andcleaned and brushed thoroughly to maintain good oral

hygiene and avoid plaque and calculus build-up. In a

recent survey, De Moor and others3 reported that most

patients never remove their jewellery or cleaning.

Piercing procedures are usually perormed without

anesthesia by unlicensed, non-medical people, who

are oen sel-trained and have little knowledge o the

anatomy o the intraoral and perioral area; serious med-

ical conditions, such as heart valve disease and bleeding

disorders; sterilization procedures; or prevention o com-

plications ollowing piercing.4

MucosalInjury

Because o its extreme vascularity and its location in

the upper airway, the tongue is particularly vulnerable to

complications, which are diverse and range rom minor

to potentially lie-threatening. Oral and dental complica-

tions associated with tongue piercings are categorized

as acute (early) or chronic (late).5 Acute complications

typically arise within 24 hours ollowing insertion o

the jewellery into the tongue and are usually conned to

injuries o weak tissues.3 Te most common immediate

acute symptoms include pain, swelling, bleeding and

localized inection.4,6 Potential complications that occur

within weeks o the piercing include unctional prob-lems, such as dysphonia, dysphagia, intererence with

mastication and the generation o galvanic currents

between the barbell and metallic dental restorations.3,7Hypersensitivity reactions, known as allergic contact

dermatitis, to the metal when jewellery is not o thebest quality or contains nickel have been reported. 8 Lesscommon acute symptoms include increased salivary fow

rates. Irritation o the skin around the jewellery inserted

into the lower lip has been shown to be related to contactallergy and to saliva fowing through the pierced site.9 In

most cases, these complications have not been detrimental

and tend to disappear with time. However, more seriousand potentially lie-threatening complications have been

reported, including prolonged bleeding,1012 inections,

disease transmission and airway problems secondary toswelling o the tongue.10,13,14 Finally, the potential risk o

aspiration or inhalation o parts o the jewellery i theycome loose should not be overlooked.1,3,4

RiskofHemorrhage

Although in 1977 Boardman and Smith1 stated thatbleeding is not the most requent complication o tongue

piercings, prolonged bleeding is o great concern in med-

ically compromised patients. During the piercing process,blood vessels may be torn and vascular nerves damaged.

Hardee and others11 reported a signicant loss o blood

rom hemorrhage ollowing a tongue piercing, whichresulted in hypotensive collapse. Prolonged bleeding,

hematomas and disturbed wound healing have also beenreported ollowing lip piercings.3 Because o the signi-cant complications that may arise when hemorrhage oc-

curs, intraoral and perioral piercings should be regulated

by licensing piercing establishments. Hardee and others11have suggested that all establishments should be given

documentation on potential problems and the manage-

ment o bleeding. Furthermore, a systematic review othe customers medical history beore the piercing pro-

cedure should be recommended to rule out a history o a

bleeding disorder.12

LocalizedTissueOvergrowthAmong later complications ollowing oral piercings,

traumatic injuries to the mucosal suraces at the pier-

cing site have been documented. Tese include enlarge-

ment o the piercing hole,4 chemical burns associatedwith excessive aercare,15 paresthesia,6 sialadenitis,16

lymphadenitis,1719 sarcoid-like oreign-body reactions,20

granulomas and scar tissue ormation at the piercingsite aer the removal o a labret or barbell. 3,9 Moreover,

barbell shanks that are too short may lead to localized

tissue overgrowth, with the mucosal surace o the tonguehealing over the barbell.21 Lingual piercings that become

Airway compromise

Allergic reaction to metal

Bleeding and risk o hemorrhage

Galvanism

Gingival recession

Hyperplasic and scar tissue ormation

Increased salivary fow

Inhalation o the jewellery

Intererence with radiographic images

Intererence with speech, chewing and swallowing

Localized and systemic inections

Nerve damage and paresthesia

Pain

Swellingooth racture or chipping

Box1 Risks and complications associated with oralpiercings


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embedded (buried) in the ventral5 or dorsal surace o thetongue have been reported.21,22 In contrast, an excessivelylong shank (long-stem barbell) may allow the barbell tomove in the tissue, which may lead to an infammatoryhyperplastic tissue reaction1 and the accumulation odental plaque and calculus on the shank.1,3,4,23

Intraoral piercings have also been implicated in theormation o hypertrophic keloid tissue.23,24 Keloid lesionsare ormed when unaected tissue inltrates the piercing;they are characterized by the production o an interstitialmucinous material on the collagen o connective tissue.In the episodic case o keloid or hypertrophic tissuewithout any signs o inection reported by Neiburger,23an improvement in the patients oral hygiene and a re-duction in the size o the barbell shank resulted in asignicant improvement, but did not completely resolvethe lesion. In most reported cases o tissue prolierationollowing tongue piercings, surgical interventions were

not required and complete healing occurred ollowingremoval o the jewellery.23,24

DentalTrauma

raumatic injuries to the hard dental tissue have beendirectly associated with jewellery. ongue piercings arethe most commonly reported cause o damage to thedentition. In 1997, DiAngelis25 rst suggested that tonguepiercings may result in abnormal tooth wear (abrasion)that may lead to cold sensitivity in the lower rst molarteeth caused by cracked-tooth syndrome.

eeth may be injured during speaking or masticatingor by biting the barbell or hitting it against the teeth.Injuries to the teeth are usually limited to the enamel orthe dentin but may also involve the pulp. 7,26,27 Based onpublished case reports, Campbell and others5 reportedthat ractures o the posterior teeth, including molarsand premolars, are requently caused by tongue jewellery.Physical damage to the dentition may occur within therst year o use o the device, especially i the long-shankbarbell used or initial placement is not replaced aer 2weeks.27,28 A positive correlation between the duration owear and the occurrence o trauma to posterior teeth hasbeen demonstrated.5 Other actors contributing to toothractures ollowing tongue piercing include habitual

biting or chewing o the device, barbell stem length, thesize o the ornament attached to the barbell and the typeo material used in it.

Te restorative method used or a tooth traumatizedby tongue jewellery depends on the individual case.Restorative approaches compatible with the existingtongue jewellery must be considered to increase theirclinical longevity.29 Porcelain onlays, or example, are notsuitable in the presence o barbell tongue ornaments be-cause o the brittle nature o porcelain and its low resist-ance to impact.30 Porcelain crowns may also be chippedby tongue jewellery. Tus, patients should be advised to

remove the oral jewellery permanently or to replace metal

balls with non-metallic ones. Recently, so rubber ends

and acrylic screw caps have become available and are

considered less likely to cause tooth chipping.

GingivalTrauma

Increasing numbers o case reports have pointed to

oral piercings as a signicant actor in gingival trauma

(Fig. 1). Te nature, extent and severity o mucogingival

deects are usually categorized using Millers classica-

tion o marginal tissue recession.31 Gingival recession has

been especially correlated with lip studs or labrets1,3,7,17

and requently occurs on the labial aspect o the lower

central incisors.3,5,9,17,28,32,33 Gingival recession, particularly

on the lingual aspect o the mandibular anterior teeth,

has also been associated with tongue jewellery.3,5,7,16,32,34

A positive correlation has been demonstrated between

the prevalence o gingival recession due to tongue and lip

piercing and duration o wear.5,33 According to Campbell

and others,5 lingual recession o gingiva is observed aer

2 years o wear. Long-stem barbells signicantly increase

the prevalence o lingual recession. Recently, Leichter

and Monteith33 reported an increased incidence and se-

verity o buccal recession with lip piercing and duration

o wear.

Jewellery-associated recession requently develops

as a narrow, cle-like deect on the lingual and buccal

aspects o the mandibular incisors, 32 with recession

depths o 23 mm or more oen extending to or beyond

the level o the mucogingival junction.5 Patients with

oral jewellery may also be at risk o developing signi-

cant loss o periodontal attachment that may lead to

tooth loss.32 Severe attachment loss can develop even

when gingival recession is minimal.5 Because attach-

ment loss may escape detection,5,32,35 regular checks o

the periodontium and examinations or gingival reces-

sion, especially on the lingual aspect o the anterior teeth,

are recommended or patients with oral piercings or a

history o oral piercings.5,35

Figure1: Localized gingival recession due tothe presence of lip piercing.


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LocalizedInfections

Because piercings invade the subcutaneous tissues,

they have an inherently high potential or inectious

complications. During piercing procedures, inection

control standards, which include the use o disposable

gloves, sterile or disposable instruments and sterilized

jewellery, should be ollowed. However, as body pier-

cing remains largely unregulated, it is oen perormed

without adequate cross-inection protection and hygiene

measures. Tus, oral piercing customers are at high risk

o developing localized and generalized systemic

inections.

Inections are the most common generalized compli-

cation o tongue piercings.6,13 One recent report estimated

a 20% inection rate with intraoral piercing.36 Te ac-

cumulation o dental biolm and calculus at pierced sites

may promote the development o inections.10 reatment

includes improving oral hygiene with the use o antiseptic

oral cleanser, the administration o adequate antibiotic

therapy and surgical drainage and incision o abscess.

SystemicInfections

Te open wound at the pierced site may also be a

source o systemic inectious complications as it may

allow microorganisms to enter the bloodstream. Tis may

lead to subsequent inection o other organs by microor-

ganisms inhabiting the oral cavity. Recurrent bacteremias

may constitute a threat long aer tongue piercing, espe-

cially in immunocompromised people.37

Rheumatic heart disease, congenital deormities,hypertrophic cardiomyopathy, mitral valve prolapse as-

sociated with murmur and mitral calcication have been

cited as predisposing actors. Inective endocarditis may

be caused by metastatic oral bacteria. Once bacteria have

entered the bloodstream, the subsequent colonization o

the endocardium typically aects valves with congenital

or acquired dysunction. Inective bacterial endocard-

itis ollowing body piercing is relatively rare. However,

over the past ew years, an increasing number o case

reports have described episodes o inective endocarditis

ollowing tongue piercings.3740 A recent survey investi-

gating the practice o tongue piercing revealed that ewpiercers are aware o the risk o bacterial endocarditis in

certain categories o people.4

o avoid the serious sequelae o these inections, pa-

tients at risk o endocarditis should receive preventive

antibiotics beore the piercing procedure just as those

at high risk o complications receive antibiotic treat-

ment beore invasive dental procedures.41 Although rela-

tively rare, other serious lie-threatening complications,

such as the development o cerebral brain abscesses 42

and Ludwigs angina,43 as a result o inections ollowing

tongue piercings have been described.

Inadequate aseptic surgical techniques and inappro-priate instrument sterilization during piercing proced-ures may signicantly increase the incidence o inectiousdisease transmission.Although no statistical studies as-sessing the potential risks o inectious disease trans-mission ollowing oral piercing have been reported, the

National Institutes o Health identied piercing proced-ures as a possible means o transmission o bloodborne viruses, such as hepatitis and human immunodeciencyvirus.44 Hepatitis B and C are the most common virusestransmitted by body piercing.45 Many have suggested thatoral piercing may allow transmission o human immuno-deciency virus, although no reports have appeared inthe literature.

Conclusion

ongue and lip piercings represent a signicant riskor direct and indirect damage to so and hard oral tis-

sues. Although much less prevalent, lethal systemic inec-tions may also occur. Considering the growing popularityo intraoral and perioral piercings, dental proessionalsshould be aware o the potential complications associatedwith this practice and be able to identiy those at highrisk or adverse outcomes. ogether with parents andeducators, dental proessionals should play an active rolein warning patients o the serious consequences o oralpiercing and should provide appropriate guidance. a

THE AUTHORS

Dr. Maheu-Robertis a dentist at the Basse-Cte-Nord HealthCentre, Lourdes-de-Blanc-Sablon, Quebec.

Dr. Andrian is a ormer PhD student in the Oral EcologyResearch Group, aculty o dentistry, Laval University,Quebec City, Quebec.

Dr. Grenier is proessor in the aculty o dentistry and dir-ector o the Oral Ecology Research Group, Laval University,Quebec City, Quebec.

Correspondence to: Dr. Daniel Grenier, Oral Ecology Research Group,Faculty o Dentistry, Laval University, Quebec City, QC G1K 7P4.

Te authors have no declared fnancial interests.

Tis article has been peer reviewed.

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Lip Piercing